Provider-Contractor Interest Questionnaire
Hello! Thanks for taking the time to apply for a therapist position at Legacy Counseling Service. To streamline the process and be sure we are an appropriate match, please fill out this questionnaire. Thank you!
Email address *
First and last name
Your answer
Please watch this brief video about Legacy Counseling Service before completing the rest of this form.
Are you fully licensed as an LCPC, LCSW, LMFT , Ph.D., Psy.D., or medical prescriber in the state of Oklahoma?
Please tell us about your specialty. List any certifications, previous experience, or any other information that informs us about your ability to work with that population(s).
Your answer
Are you available to work (seeing clients) at least 15 hours per week?
Are you available and willing to work nights and/or weekends?
Please discuss you ideal schedule.
Your answer
Do you have previous private practice experience?
If yes, please tell us about your previous private practice experience.
Your answer
Our practice is very collaborative. We focus on helping the community by way of marketing, networking and providing community speaking engagements. Are you comfortable with this?
Not at all comfortable
Very comfortable
Our clinicians are able to work independently and follow directions easily. Do you feel comfortable working independently and being able to follow through on scheduling your existing clients, taking co-pays or payment, keeping notes accurate and timely, responding to emails in a timely fashion, and staying organized?
Not good at this at all
I'm awesome at this
The therapists at Legacy are active Christians and many of our clients choose to work with us because of our Christian values. Are you comfortable with this and discussing how a client's spiritual (Christian or otherwise) beliefs influence their mental health?
Not at all comfortable
Very comfortable
Are you currently paneled with insurance companies? If so, which one? *
Your answer
Why are you interested in working at Legacy Counseling Service?
Your answer
How did you find Legacy Counseling as a possible place to work?
Your answer
What are your long term goals (1-3 years out)? Personally and/or professionally.
Your answer
What can you bring to Legacy Counseling Service that sets you apart from other candidates?
Your answer
Tell us about your personality. How would colleagues describe you?
Your answer
Please email a cover letter, your resume, and the name, relationship, and contact information for three references who can speak to your recent individual therapy skills to drleedy@legacycounselingservices.com.
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This form was created inside of Legacy Counseling Service.